Diapositiva 1

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Smoking and Diabetes
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BACKGROUND- As documented in the American
Diabetes Association's technical review "Smoking
and Diabetes", a large body of evidence from
epidemiological, case-control, and cohort studies
provides convincing documentation of the causal
link between cigarette smoking and health risks.
Cigarette smoking is the leading avoidable cause
of mortality in the U.S., accounting for 400,000
deaths each year. Cigarette smoking accounts for
one out of every five deaths in the U.S. and is
the most important modifiable cause of premature
death. Cigarettes provide the delivery system for
nicotine, an addictive substance related to
various pharmacological, biochemical, and
psychological processes that interact to support
a compulsive pattern of drug use.
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Much of the prior work documenting the impact of
smoking on health did not discuss separately
results on subsets of individuals with diabetes,
suggesting the identified risks are at least
equivalent to those found in the general
population. Other studies of individuals with
diabetes consistently found a heightened risk of
morbidity and premature death associated with the
development of macrovascular complications among
smokers. The cardiovascular burden of diabetes,
especially in combination with smoking, has not
been effectively communicated to people with
diabetes or to health care providers, and there
is little evidence that this risk factor is being
addressed as consistently and comprehensively as
its importance requires. Smoking is also related
to the premature development of microvascular
complications of diabetes and may even have a
role in the development of type 2 diabetes.
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General smoking prevalence decreased
substantially up until about 1990 because of
extensive public health efforts, which included
making the population aware of the health hazards
of active and passive smoking, implementation of
smoking cessation interventions, and policy
changes. However, since then there has been very
little further reduction, and about 25 of
American adults continue to smoke, with
variations reported by ethnic and
sociodemographic groups. These figures mirror the
prevalence of tobacco use among individuals with
diabetes. It appears that adolescents may
initiate smoking after being diagnosed with
diabetes and that the prevalence of tobacco use
decreases with disease duration.
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Effectiveness of smoking cessation counseling
Smoking cessation is one of the few interventions
that can safely and cost-effectively be
recommended for all patients, and it has been
identified as a gold standard against which other
preventive behaviors should be evaluated. A
number of large randomized clinical trials have
demonstrated the efficacy and cost-effectiveness
of certain forms of provider and behavioral
counseling in changing smoking behavior of
primary care and hospitalized patients. This
work, combined with the more limited studies
specific to individuals with diabetes, suggests
that smoking cessation counseling is effective in
reducing tobacco use in this high-risk group.
This evidence has been summarized in the updated
clinical practice guideline from the U.S. Public
Health Service "Treating Tobacco Use and
Dependence.
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Several treatment characteristics have been
identified as critical to achieve cessation.
These characteristics include brief counseling by
multiple health care providers, use of individual
or group counseling strategies, and use of
pharmacotherapy. Effective pharmacotherapies now
include nicotine replacement therapy in a variety
of forms (gum, patch, inhaler, spray) and
antidepressants (bupropion and nortriptyline).
Although many large-scale well-controlled outcome
studies have included patients with diabetes, few
have reported results separately for patients
with diabetes versus other participants. Special
issues that affect successful abstinence have
been identified in these studies and include
weight management and depression.
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Postcessation weight gain may be an impediment to
smoking cessation, especially among women or
other people concerned with weight management.
The presence of comorbid psychiatric conditions
such as depression is associated with a greater
prevalence of smoking and an increased risk of
relapse after quitting. Though not reported
separately, these issues are expected to be at
least equally relevant for diabetic patients as
for general patients.
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Smoking cessation delivery systems
Despite demonstrated efficacy and
cost-effectiveness, smoking cessation has not
received the priority it deserves from health
care providers. Only about half of smokers with
diabetes have been advised to quit smoking by
their health care providers. One important means
of assuring systematic advice regarding the
prevention and cessation of tobacco use is
through the implementation of smoking cessation
delivery systems in office practices and
hospitals. These systems require organizational
changes in clinics and hospitals to
systematically identify all tobacco users at
every visit, so that evaluation of smoking status
becomes a routine vital sign.
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After tobacco users have been identified by
staff, clinicians should provide a brief
assessment of interest in quitting, advise those
without current interest how important it is to
quit, and connect those prepared to quit with
those who can provide further information,
assistance, and follow-up.
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RECOMMENDATIONS
Substantial evidence supports inclusion of the
prevention and cessation of tobacco use as an
important component of state-of-the-art clinical
diabetes care. Health care providers engaged in
the care and management of individuals with
diabetes should follow the approach summarized in
Table 1 and address the following primary areas.
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Table 1-Recommendations regarding diabetes and
smoking (E) From   anonymous Diabetes Care,
Volume 27 Supplement 1.January 2004.S74-S75
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Ask
The routine assessment of current tobacco use is
a critical first step toward encouraging
cessation. The nurse or medical technician who
prepares patients for their visit should do this.
Nonsmoking adults are unlikely to start, so a
sticker on their charts can prevent having to ask
them at each visit.
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Assess
In those who are current tobacco users, it is
important to assess their interest in quitting by
asking if they are ready to quit in the next 30
days (preparation phase) or in the next 6 months
(contemplation phase). Knowledge of this
readiness stage allows tailoring of the
intervention to each individual.
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Advise
Health care providers should advise all smokers
with diabetes how important it is for them to
quit. There is a dose-response relationship
between type, intensity, and duration of
treatment and smoking cessation. In general,
minimal interventions are defined as lt3 min of
counseling, whereas brief interventions are
defined as 3-10 min of counseling. While more
intense interventions are most effective in
producing long-term abstinence from tobacco, few
smokers are willing to participate.
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Assist
The keys to assistance are helping the smoker to
set a quit date, providing information about how
to prepare for that date, and offering counseling
and/or medication assistance to those who are
interested. Several pharmacological agents
increase smoking cessation rates when used in
conjunction with behavioral interventions. These
include 4-6 weeks of nicotine replacement
therapy, bupropion (150 mg p.o. q.d. or b.i.d.)
or nortriptyline (25-75 mg p.o. q.h.s.).
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Arrange
In addition to providing support and
pharmacological assistance to smokers who are
ready to quit, health care providers should also
make arrangements for a follow-up phone call soon
after the quit date. This can be done by clinic
staff. Smokers receiving pharmacotherapy should
also have a return office visit arranged.
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Organize your clinic
Effective systems for implementing these
guidelines should be incorporated into the
routine practice of diabetes care. Recording
smoking status as a vital sign increases
identification of current tobacco users.
Organized office information systems and
delegation of cessation support and follow-up to
trained office staff will greatly increase
tobacco cessation rates.
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Advocacy for tobacco control through public
policy initiatives is also an appropriate and
potentially effective way to reduce the burden of
excess morbidity and mortality that tobacco use
confers on those with diabetes.